I never even met one of the patients who had the most enduring impact on me. I was just a fourth-year medical student on rotation with the neurosurgery service, excited to participate in a cool, complex case. At my level, I would be relegated to scrubbing in and watching. The chief resident made me feel like part of the team, though, by discussing the case with me and granting me the dubious honor of placing a catheter in the patient's bladder, a lowly but necessary task. I also took the initiative to write some orders in the chart based on what I knew the woman would need after surgery. These orders would turn out to be unnecessary.

I learned from my chief resident that the patient, intubated and asleep in front of me, was young--a teenager really--who decided to undergo surgery only after painful deliberation. Years earlier she had been diagnosed with a large malformed tangle of blood vessels in her brain--an arteriovenous malformation, or AVM. Unfortunately, this AVM was of an extreme type--very large and in a very dangerous location. The situation is informally known among neurosurgeons as a "handshake AVM": as the patient walks out of the neurosurgeon's office after a consultation, a handshake is all the surgeon has to offer.